Emmanuel Chartier-Kastler

High-intensity focused ultrasound in prostate cancer; a systematic literature review of the French Association of Urology.

We discuss the efficacy and safety of high‐intensity focused ultrasound (HIFU) in patients with prostate cancer, to define the best indications for HIFU in daily clinical practice as primary therapy. We searched Medline and Embase for clinical studies evaluating the efficacy and safety of HIFU in prostate cancer (July 2007), and abstracts presented at the 2005–2007 annual meetings of the European Association of Urology and American Urological Association were screened. In all, 37 articles/abstracts were selected. As the data on HIFU as salvage therapy were limited, we focused on HIFU as primary therapy. Studies consisted of case series only. Included patients were ≈70 years old with T1‐T2 N0M0 disease, Gleason Score ≤7, a prostate‐specific antigen (PSA) level of ≤28 ng/mL and a prostate volume of ≤40 mL. Negative biopsy rates with the AblathermTM device (EDAP TMS S.A., Vaulx‐en‐Velin, France) were 64–93%, and a PSA nadir of ≤0.5 ng/mL was achieved in 55–84% of patients. The 5‐year actuarial disease‐free survival rates were 60–70%. The most common complications were stress urinary incontinence, urinary tract infection, urethral/bladder neck stenosis or strictures, and erectile dysfunction. For the Ablatherm device, the rate of complications has been significantly reduced over the years, due to technical improvements in the device and the use of transurethral resection of the prostate before HIFU. In conclusion, HIFU as primary therapy for prostate cancer is indicated in older patients (≥70 years) with T1‐T2 N0M0 disease, a Gleason score of <7, a PSA level of <15 ng/mL and a prostate volume of <40 mL. In these patients HIFU achieves short‐term cancer control, as shown by a high percentage of negative biopsies and significantly reduced PSA levels. The median‐term survival data also seem promising, but long‐term follow‐up studies are needed to further evaluate cancer‐specific and overall survival rates before the indications for primary therapy can be expanded.

Urinary Incontinence in French Women: Prevalence, Risk Factors, and Impact on Quality of Life

BACKGROUND The lack of epidemiologic data on the prevalence of female urinary incontinence (UI) attending general practitioners (GPs) in France led us to conduct a cross-sectional study in our country. OBJECTIVES To determine the prevalence of UI and to assess its impact on the quality of life (QoL). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of women aged >18 yr was conducted by attending GPs between June 2007 and July 2007. MEASUREMENTS The main outcome measures were urinary symptoms, functional impairment, International Consultation on Incontinence Questionnaire-Short Form score, and medical care seeking. RESULTS AND LIMITATIONS Overall, 241 GPs enrolled 2183 women seen during 1 d. The prevalence of UI was 26.8% (n=584) and increased with age, body mass index (BMI), and number of children delivered (p<0.0001). Among women with UI, 496 were included in a cross-sectional survey: 45.2% (n=224) had stress UI, 42.1% (n=209) had mixed UI, and 10.9% (n=53) had urge UI, while 2% (n=10) had UI of indeterminate type. Overall, 288 of 496 women (51.8%) stated that UI had a negative impact on their QoL; this effect remained mostly mild or moderate, and only 197 of 496 women (39.7%) had asked for medical help. Longer duration of symptoms, higher frequency of comorbid urinary symptoms, and altered QoL were most frequent among women with mixed UI (p<0.001). Misclassification may have occurred because the diagnosis of UI was based on self-reported data rather than on clinical or urodynamic examinations. CONCLUSIONS UI symptoms were found in almost one in four women attending GPs. Clinical and functional UI impairment were associated with age, BMI, and parity. UI caused distress to women, but only those who were severely affected sought help. The results emphasize the need for policy development for UI prevention and management in France.

Botulinum toxin-A (Botox) intradetrusor injections in children with neurogenic detrusor overactivity/neurogenic overactive bladder: a systematic literature review.

OBJECTIVES Describe and discuss the efficacy and safety of botulinum toxin type A (BTX-A) intradetrusor injections in children with neurogenic detrusor overactivity (NDO) and urinary incontinence or overactive bladder symptoms of neurogenic origin (NOAB). METHODS A MEDLINE and EMBASE search for clinical studies involving BTX-A injected into the detrusor of children with NDO or NOAB was performed, prior to data analysis. RESULTS A total of six articles evaluating the efficacy and safety of Botox in patients with NDO and incontinence/NOAB were selected. The underlying neurological disease was myelomeningocele in 93% of patients. Most were over 2 years of age. The most common amount of Botox injected was 10-12 U/kg with a maximal dose of 300 U, usually as 30 injections of 10 U/ml in the bladder (excluding the trigone) under cystoscopic guidance and general anaesthesia. Most of the studies reported a significant improvement in clinical (65-87% became completely dry) as well as urodynamic (in most studies mean maximum detrusor pressure was reduced to <40 cm H(2)O and compliance was increased >20 ml/cm H(2)O) variables, without major adverse events. CONCLUSIONS Botox injections into the detrusor provide a clinically significant improvement and seem to be very well tolerated in children with NDO and incontinence/NOAB refractory to antimuscarinics.

Treatment of Postprostatectomy Stress Urinary Incontinence Using a Minimally Invasive Adjustable Continence Balloon Device, ProACT: Results of a Preliminary, Multicenter, Pilot Study

OBJECTIVES To evaluate the safety and efficacy of a new minimally invasive device, Adjustable Continence Therapy (ProACT) for patients with postprostatectomy stress urinary incontinence (SUI). METHODS Sixty-two patients with urodynamic SUI after prostate surgery were evaluated according to daily pad count and a specific validated evaluation for persons with urinary incontinence. RESULTS All patients were successfully implanted in a single procedure using general or spinal anaesthesia. Procedural time was 37 minutes (range, 18 to 80 minutes). Daily pad usage decreased from 4.6 pads per day to 1.06 pads per day at 12 months. Mean quality-of-life index score increased from 48 to 67 at 12 months.Fifty-nine percent of patients without adjuvant radiation were improved (greater than 50% reduction in pad use), and 30% were cured (no pads), whereas 83% of postirradiated patients failed intervention. Fifty-five patients (88%) required percutaneous balloon adjustments. The mean optimal volume after adjustments for all 45 improved patients was 3.8 mL per balloon. Complications necessitating removal occurred in 19 patients and included erosion, infection, migration, and failure to respond. Of these, 4 were successfully reimplanted. All complications occurred in the first postoperative month. CONCLUSIONS Implantation of postoperatively adjustable balloons in postprostatecomy men is technically feasible, with an improvement in continence particularly in patients with nonirradiated periurethral tissues. Optimal urethral resistance is achieved, with easy postoperative adjustment. Implantation of ProACT balloons may represent a promising development in the treatment of postprostatectomy SUI.

Long-term results of augmentation cystoplasty in spinal cord injury patients

Study design: Prospective monocentric follow-up study.Objectives: To assess long-term functional and urodynamic results of augmentation enterocystoplasty in spinal cord injury (SCI) patients with detrusor hyperreflexia and reflex incontinence who failed to respond to conservative treatment.Settings: Department of Urology (Pitié-Salpétrière Hospital, Paris, France), Department of Neurological Rehabilitation (Raymond Poincaré Hospital, Garches, France), Assistance Publique – Hopitaux de Paris, University Paris VI and V, France.Methods: Prospective study of 17 SCI patients (four above T6 level, nine between T6 and T12, and four below T12) with history of refractory urge incontinence to pharmacotherapy. Partial cystectomy (subtrigonal for 15) was performed with Hautmann enterocystoplasty (15) or detubularized clam cystoplasty (two).Results: Mean follow-up was 6.3±3.8 years (range 1.25–10.5 years). Fifteen of 17 (88.5%) patients were completely continent under self clean intermittent catheterization (CIC) (mean 4.6/day, range 4–7). The remaining two patients with pudendal nerve denervation had persistent stress urinary incontinence. No operative complications were noted. Long-term complications included recurrent pyelonephritis for one patient. Maximal cystometric capacity increased from 174.1±103.9 to 508.1±215.8 ml (P<0.05). Maximal end filling pressure decreased from 65.5±50.2 to 18.3±7.9 cm H2O (P<0.05).Conclusion: Urodynamic evaluation and clinical assessment demonstrate long-term success of augmentation enterocystoplasty in an homogeneous population (SCI) without delayed complications in SCI patients.

Side effects of chronic intrathecal baclofen on erection and ejaculation in patients with spinal cord lesions

OBJECTIVE Assess modifications of sexual function in men treated with intrathecal baclofen for spinal spasticity. DESIGN Prospective before-after trial. SETTING A rehabilitation department of a university hospital; follow-up was on an outpatient basis. PATIENTS A convenience sample of nine consecutively recruited men with spinal cord injury or multiple sclerosis who were receiving intrathecal baclofen by an implantable pump; average follow-up was 44.4 months. MAIN OUTCOME MEASURES A questionnaire focusing on: libido; ability to sustain reflexive and psychogenic erections; rigidity, evaluated by a visual analog scale; maximum duration of erection; possibility of ejaculation. RESULTS Libido and the ability to obtain psychogenic or reflexogenic erections were not modified. However, eight patients reported a decrease of erection rigidity and/or duration. Ejaculation was possible in three cases before implantation. It disappeared in two patients, and was more difficult to obtain in the last one. It reappeared after treatment withdrawal. No differences were found between multiple sclerosis and spinal cord injured patients. CONCLUSION Intrathecal baclofen may compromise erection and ejaculation. This effect is reversible. Patients should be informed of this effect.

Long‐term functional outcomes after artificial urinary sphincter implantation in men with stress urinary incontinence

To evaluate long‐term functional outcomes of artificial urinary sphincters (AUSs) and to determine how many men required explantation because of stress urinary incontinence (SUI) caused by sphincter deficiency after prostate surgery.

Phosphodiesterase inhibitors in the treatment of erectile dysfunction in spinal cord-injured men.

Study design:Open, before–after study.Objective:To assess the efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED) in spinal cord-injured (SCI) patients.Setting:Home- and clinic-based assessments in the outpatient department at the Centre Bouffard Vercelli, Cerbère France.Methods:Clinic trials with Sildenafil (Viagra®) on 120 patients, Tadalafil (Cialis®) on 54 patients and Vardenafil (Levitra®) on 66 patients were performed. Flexible doses of PDE5 inhibitors were given depending on efficacy and tolerability, from 50 to 100 mg for Sildenafil, and from 10 to 20 mg for Vardenafil and Tadalafil. Each trial was performed after a weeks interval. The efficacy was self-assessed by the patients on a six-point quantitative scale assessment. The response to treatment was assessed at home in 90 patients (57 patients on Sildenafil, 12 patients on Vardenafil and 21 patients on Tadalafil) using the International Index of Erectile Function (IIEF).Results:In clinic trials, PDE5 inhibitors were effective (rigidity enough for penetration) in 85% of the patients on Sildenafil, 74% of the patients on Vardenafil and 72% of the patients on Tadalafil. The mean duration of erection was 34, 28 and 26 min, respectively. Adverse effects were mild, usually attenuated with continued dosing. More than 70% of the patients on Vardenafil and Tadalafil required higher doses of 20 mg, whereas 50 mg of Sildenafil was effective in 55% of the patients. Two-thirds of our patients on Tadalafil reported a duration of action longer than 24 h. The presence of an upper motor neuron lesion was significantly associated with therapeutic success, lower motor neuron lesions and cauda equina patients were poor responders. Other variables such as completeness of lesion had no impact.In the follow-up visits, the IIEF global scores and three IIEF domains (erectile function, intercourse satisfaction and overall satisfaction) were significantly improved in all patients. Patients on Sildenafil showed a significant improvement of orgasmic function, ejaculation (Question 9) and orgasm (Question 10).Conclusion:Sildenafil, Vardenafil and Tadalafil are all effective and well-tolerated treatments for ED in SCI patients. Although no statistical analysis could be applied on these data, these results might indicate that Sildenafil is more effective in treating ED. Clinic trials are important for proper dose titration and appropriate education of the patients.

Intermittent Catheterization With Hydrophilic Catheters as a Treatment of Chronic Neurogenic Urinary Retention

Neurogenic bladder can be effectively managed with intermittent catheterization (IC) to improve or restore continence, but there is no consensus on which type of catheter is preferred. Hydrophilic catheters were developed to reduce urethral friction, thereby minimizing trauma and sticking, and making them more acceptable to the patient, and easier and safer to use. The objective of this article was to review the literature on the benefits of hydrophilic catheters in patients with neurogenic bladder.

Neurogenic bladder management and cutaneous non-continent ileal conduit.

Study design: Prospective monocentric follow-up study.Objectives: To assess the results of cutaneous non-continent diversion for neurogenic bladder management.Settings: Department of Urology (Pitié-Salpétrière Hospital), Department of Neurological Rehabilitation (Raymond Poincaré Hospital), Assistance Publique-Hopitaux de Paris, University Paris VI and V.Methods: We reviewed the charts of 33 consecutive patients (19 women, 14 men), operated between 1979 and 1999. Twenty-one patients had spinal cord injury (SCI), four had multiple sclerosis, three had various forms of myelitis and five had central neurological diseases. Diversion was indicated for upper urinary tract protection (17), perineal dryness (14) and/or functional or social reasons (20). Before the operation, 20 of the 33 patients (60.6%) presented urologic complications related to bladder management, including triggered micturition, indwelling catheter or intermittent catheterization: urethrocutaneous fistula (4), complicated enterocystoplasty (2), watering pot perineum and severe decubitus ulcerations (14). Ileal conduit (also named ileoureterostomy) was performed alone for 19 patients (57.6%), and in combination with simultaneous cystectomy in 14 patients. We reviewed patient outcome and early and late complications.Results: Mean follow-up was 48 months (1 to 20 years). All problems related to catheters or incontinence had resolved. There were no deaths or early re-operations. Twelve patients (12 out of 33, 36%) had one or more peri-operative complication, including ileus (1), uretero-ileal anastomosis leak (1) and sepsis (1). During follow-up, four of the 19 patients who did not undergo cystectomy developed pyocystitis (3 secondary cystectomies performed between 6 and 56 months). All patients achieved perineal dryness.Conclusions: The ileal conduit procedure is a safe and well-tolerated procedure in neurologically impaired patients. This procedure is suitable for most neurogenic patients with refractory lower urinary tract dysfunctions.